Provider Demographics
NPI:1396548384
Name:WEAVER, JARRED DALTON
Entity type:Individual
Prefix:
First Name:JARRED
Middle Name:DALTON
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6129 KERRY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3513
Mailing Address - Country:US
Mailing Address - Phone:307-287-7044
Mailing Address - Fax:
Practice Address - Street 1:2526 SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3159
Practice Address - Country:US
Practice Address - Phone:307-287-7044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker